The best of both worlds

The best of both worlds Long-term care: By joining forces with a housing association, one trust has been

able to provide long-term care in purpose-built accommodation and retain clinical responsibility for patients. Diana Carne, Nina Barnett and Michael Denham report More than 200,000 physically frail elderly people are in long-term care.Many consultant physicians in geriatric medicine support a strong NHS role for those needing long-term nursing care because of its quality of nursing and multi-professional approach to care. They fear that transfer to the private sector might result in a loss of these features. But the quality of long-stay accommodation in the private sector is often better than that of the NHS, where old 'Nightingale'wards are inappropriate for continuing care and single rooms with en-suite facilities are the exception rather than the rule. The concept of the NHS nursing home was a possible solution, but not widely pursued. The ideal situation would be an amalgam of the best of the NHS with the private and voluntary sectors: the NHS would continue to provide good quality nursing care with ready access to all members of the multi-professional team, while the latter provided high-quality accommodation and general administrative support. In 1998, Harrow and Hillingdon Healthcare trust and Sanctuary Housing (a voluntary, non-profit making housing association) reached an agreement on leasing arrangements for NHS continuing-care patients to be transferred from wards to purpose built accommodation constructed by the association. Sanctuary Housing provided furniture and£3m funding. The trust provided specialist equipment such as hoists. The unit is about two-and-a-half miles from Northwick Park Hospital, and opened in November 1998. The average age of residents is 85. The patients remain fully under the control of the NHS and occupy 30 beds on the first floor of a three-floor building. Two of these beds are regularly allocated for respite admissions, such as those with end-stage cancers or long-term neurological conditions. The cost to the NHS is about£700 per patient per week. Clients of the voluntary organisation occupy the ground and second floors. The collaboration has been a great success, due to the design skills and management expertise of the voluntary organisation - its support services have allowed the trust's unit manager more time for clinical duties - and the continuation of professional input from the multidisciplinary team. The unit is staffed by 13 nurses (one G grade, two F, six E and four D) and 20 healthcare assistants. The consultant physician in geriatric care has clinical responsibility for the unit, while day-today care is provided by a GP. Sanctuary designed excellent accommodation. Each patient room has en-suite facilities and every resident is able to bring a favourite item of furniture and may redecorate their room. There are large day rooms, each with kitchen areas, as well as bathrooms, quiet rooms, office areas, and a large patio. The general support services include security, laundry, maintenance, cleaning, refuse and catering. The meals are interesting and imaginative. There has been a positive attitude towards collaboration between the two organisations. The officer in charge of the voluntary home organises cleaning rotas, general stores supplies, maintenance, hair-dressing facilities and car park attendance, plus the catering and security arrangements. The unIt is NHS manager only needs to keep a 'light hand on the administrative tiller'. The unit manager now has time to greet all relatives who want to view rooms before the elderly resident arrives, to allay any anxieties they may have, and begin a partnership in care for the benefit of the patient. The patients' hospital notes and medication charts are transferred with them, helping maintain continuity of care. This enables an accurate care plan to be designed. Patients transferred from hospital feel more settled and less 'harried' in this unit. And the unit manager has time to act as lead nurse for some patients. She has taken a major role in maintaining nursing morale with regular information meetings, news sheets, and discussion of staff 's personal problems. Sessions are held on risk assessment and ethical issues. She arranges for staff to attend NVQ courses or study days and visits to specialist units. The unit now has Project 2000 students for six-weekly placements. It has also been involved, together with the acute geriatric unit at Northwick Park Hospital, in the Royal College of Nursing's older persons holistic care project.

Many letters of commendation have been received, but no complaints. Nurses from the acute hospital often visit to see their former patients and have been surprised to see how much they have improved. The growing reputation of the unit has resulted, on occasion, in senior officers in the trust being 'pressured' to accept a new patient from outside our usual admitting areas. Usually, there is little or no waiting list for admission. There are fortnightly consultant ward rounds in addition to weekly visits by a GP who is paid for two sessions a week by the trust. He is responsible for all the patients' daily care and liaises with the consultant, nurses and the members of the multiprofessional team, which produces good continuity of care. A pharmacist also visits the unit each week to review medication. Drug therapy is reviewed regularly and the question of continued need addressed and the risk/benefit of stopping or modifying considered. These measures were in force well before the recommendations of the national service framework for older people. A physiotherapist and occupational therapy assistants are based in the unit and work daily with the patients. The work boundaries between nurses, nursing assistants and therapy assistants are treated flexibly for the benefit of the patient. A dietician visits regularly and advises in particular on patients who are being fed via a percutaneous endoscopic gastrostomy - at one time nine out of 30 patients were being fed in this manner. Over time, it proved possible to feed many of these patients normally.A chiropodist, dentist and optician screen patients and visit as required. Many other professionals call in to give advice, including specialist nurses in diabetes, continence, stoma care, infectious diseases and Parkinson's disease. A social worker also calls as necessary. Macmillan nurses provide special help and give staff training sessions. All these professionals are readily available to the patients in the NHS unit. This contrasts with private care where GPs covering their patients in private beds have to request input of this type - with consequent delays. Despite the regular visits by a consultant geriatrician and other NHS professionals, the placing of the unit within a building owned by a voluntary organisation raised concerns among some staff that the unit might cease to be part of the NHS and was on the path to privatisation. The nurse manager had to reassure both staff and patients that the unit intends to remain part of the NHS. This was a problem because the unit lacked a definite identity of its own. The hurdle was overcome by naming the unit after a recently retired, well-known consultant geriatrician.This quickly proved to be of great benefit for staff and the referring hospitals.The staff take pride in being part of the NHS and in the care they provide. At a time of nurse shortages and blunted morale, and when nurses can pick and choose where they work, staff sickness rates (1.87 per cent) and nurse/nurse assistant turnover are low. Indeed, no staff have left in the past 12 months.Agency hours are minimal, so there is excellent continuity of care, something that facilitates good communication between patients and staff - as the patients themselves have remarked. Diana Carne is unit manager, Nina Barnett is specialist pharmacist, care of older people, and Dr Michael Denham is honorary consultant physician in geriatric medicine, Denham unit, Harrow and Hillingdon Healthcare trust. REFERENCES 1Laing and Buisson. Care of Elderly People Market Survey 2001. 14th edition. Laing and Buisson. 2Bond J, Gregson BA, Atkinson A.Measurement of outcomes within a multicentred randomised controlled trial in the evaluation of the experimental NHS Nursing Home. Age and Ageing 1989; 18(5): 292-302. 3Kellett J. Long Term Care on the NHS: a vanishing prospect. Br Med J 1993; 306 (6881): 846-8. Key points    

An NHS/housing association venture has produced good accommodation for 30 elderly people in need of longterm care. The housing organisation takes responsibility for support services such as laundry, cleaning, security and catering. The unit remains part of the NHS. Patients appreciate the environment and staff turnover is low.

7 March, 2002 https://www.hsj.co.uk/home/the-best-of-both-worlds/21533.article Published: 07/03/2002, Volume II2, No. 5795 Page 30 31